[Management of loss of substance in massive facial injuries]

In a communication illustrated by numerous photographs, the author describes the methods normally used in the treatment of open facial trauma. The first basic principle is the treatment of those parts of the facial skeleton fractured by the cutaneo-musculo-mucosal lesion caused by the accident. All of the fixation procedures used in closed fractures are valid. Choice depends upon the type of fracture. Loss of bone substance should be treated by immediate graft only in cases where there is no secondary infection, on condition that the mucosal and cutaneous layers which will be used as a covering are of good quality. The second rule is that lesions of the soft tissues should be treated at the same time, after having ensured repair of any bony injuries. Reconstruction may be a veritable jigsaw puzzle and magnifying instruments are useful under such circumstances. The mucosal, muscular and cutaneous layers are closed in succession. In the case of loss of substance, various forms of plastic surgery may be used in relation to the type of lesion. The following procedures are used, in descending order of frequency: -Sliding of neighboring tissues. -Free grafts--whole or partial thickness of skin. -Unipediculated flaps. -Cylindrical flaps. The third rule is that it should not be attempted to close a large defect at all costs, especially if the quality of the tissues is not excellent. In cases of this sort, it is preferable to approximately draw together the edges of the wound using large interrupted sutures on buttons. Closure of the loss of substance is delayed until later. Plastic surgery carried out by amateurs may result in catastrophe. Errors in operative technique always have irremdiable consequences for the injured patient. Prudence and caution are thus the golden rule.